Management of the Abdominal Surgical Wound

1285

THE LANCET LONDON

13

DECEMBER

1969

Management of the Abdominal Surgical Wound WOUNDS become infected because

they are inadequately excised, because, although only slightly contaminated, they contain large foreign bodies (for example, a hip prosthesis), because the patient is unable to mobilise defences against infection, or because they are heavily inoculated with organisms either at the time they are made or later. The first three of these causes can usually be countered in various well-tested ways: there is no excuse for inadequate wound excision; special operating-room conditions can protect the patient undergoing complex surgery and the insertion of prostheses 1,2 (and they deserve wider application); and in patients whose defences are incapacitated precautions are needed during and after the operation, by means of either sterile units 3-5 or life islands.s-8 There remains the apparently intractable problem of the heavily contaminated but otherwise surgically satisfactory wound, such as must be made in the abdominal wall to reach a perforated viscus. Battle surgery9 has taught and retaught that the least favourable environment for bacteria is the open wound that has been thoroughly excised. Support for this clinical view and at least a partial explanation now comes from experiments 10 which suggest that the wound builds up an intrinsic resistance at least to staphylococcal inoculation during the preparatory phase of healing, so that by the third day it can be closed even though it remains heavily contaminated. The reason for this resistance is uncertain, but it may be merely the formation of a fibrinous pellicle at the raw surface. Delayed primary closure can now be regarded partly as a technique which protects the patient from the deleterious effects of infection in a closed wound and partly as a waiting period in which the wound acquires the ability to deal with organisms which may be present initially or inoculated later. 1. 2. 3.

Charnley, J. Br. J. Surg. 1965, 51, 195. Charnley, J., Eftekhar, N. ibid. 1969, 56, 641. Mathe, G., Amiel, J. C., Schwarzenberg, L. Ann. N.Y. Acad. Sci. 1964, 114, 368. 4. Bowie, J. H., Tonkin, R. W., Robson, J. S., Dixon, A. A. Lancet, 1964, ii, 1383. 5. James, K. W., Jamieson, B., Kay, H. E. M., Lynch, J., Ngan, H. ibid. 1967, i, 1045. 6. Haynes, B. W., Hench, M. E. Ann. Surg. 1965, 162, 641. 7. Schwartz, S. A., Perry, S. J. Am. med. Ass. 1967, 197, 105. 8. Barnes, R. D., Tuffrey, M., Cook, R. Lancet, 1968, i, 622. 9. ibid. 1969, i, 1084. 10. Edlich, R. F., Tsung, M., Rogers, W., Rogers, P., Wangensteen, O. H. J. surg. Res. 1968, 8, 585.

During many abdominal operations heavy inoculation, usually with gram-negative rods, is inevitable, despite local precautions such as wound towels. Infection-rates of conventionally handled wounds are high; for example, about 25% in that useful reference condition acute appendicitis," and up to 26% in planned hollow-viscus surgery.12 The experiences of war and of the laboratory suggest two approaches which might be used alone or in combination to reduce this high attack-rate, and recent reports testify

may be

the value of both. Either the wound left open or chemoprophylaxis may be used at a time when organisms are about to establish themselves but have not yet formed a resident colony difficult to dislodge. By exploiting the first method (originally suggested by WiLKiE 13), GROSFELD and SOLIT 14 reduced the incidence of wound infection after perforated appendicitis from 14-6% to 2-3%. Of great

to

interest, though

easily explained, was a comparable reduction in intraperitoneal sepsis when wounds were left open. There is no practical disadvantage to the open wounds, which are easily closed by tying previously inserted sutures or by applying not

adhesive porous tape. both local and general, has tended to get itself a bad name, probably because of its postoperative use,15 but is well on the way to restoring its reputation. POLK and LOPEZ-MAYOR,16 building on earlier experimental work ’17 "’ have now shown in a convincing double-blind trial that saturation of the patient with a systemic broad-spectrum antibiotic in the immediate preoperative and postoperative period significantly reduces wound morbidity in abdominal surgery. The antibiotic (on a variety of indications) was cephaloridine, and not only is the cost slight compared with that of infected wounds but also the regimen of three doses of 1 g. is well below the toxic level. Even this approach could perhaps be simplified, since RICKETT and JACKSON,19 also studying appendicectomy wounds, achieved as striking a reduction in infection-rate by the use of topical ampicillin. Their trial confirms and supplements earlier work in colon surgery 20 and in hernia repair,21 and suggests that the matter should be investigated further and by similar techniques in other abdominal wounds. While topical chemotherapy avoids using the sledge-hammer of parenteral antibiotics to prevent local sepsis,2O it is still not clear whether it is really necessary. Possibly even simpler irrigation techniques may work. Saline solution is

Chemoprophylaxis,

11. 12.

13. 14. 15. 16. 17. 18. 19. 20. 21.

Vinnicombe, J. Br. J. Surg. 1964, 51, 328. Quick, C. A., Brogan, T. D. Lancet, 1968, i, 1163. Wilkie, D. P. D. Ann. Surg. 1934, 100, 202. Grosfield, J. L., Solit, R. W. ibid. 1968, 168, 891. McKittrick, L. S., Wheelock, F. C. Surgery Gynec.

Obstet. 1954, 99, 376. Polk, H. C., Lopez-Mayor, J. F. Surgery, St. Louis, 1969, 66, 97. Burke, J. F. L. ibid. 1961, 50, 161. Howe, C. W. Surgery Gynec. Obstet. 1966, 123, 507. Rickett, J. W. S., Jackson, B. T. Br. med. J. Oct. 25, 1969, p. 206. Nash, A. G., Hugh, T. B. Br. med. J. 1967, i, 471. Ryan, E. A. Br. J. Surg. 1967, 54, 324.

1286

ineffective experimentally and clinically, but other agents may be more potent.22 Meanwhile topical ampicillin seems a good agent for abdominal surgery when a septic field is entered or a hollow viscus incised. The wound is perhaps the most neglected part of an abdominal operation, and yet to the patient its firm and uncomplicated healing yields dividends of short stay in hospital, rapid reablement, and freedom from complications. And any reduction in infection-rate makes for more efficient use of expensive resources. Surgeons should profit from the new outlook in management and chemotherapy which these trials present. " Cut well, sew well, get well " remains a fine axiom, but to it must now be added " choose well " in the management of the wound.

relatively

More Should Mean Different Two events have triggered off the sensational headlines about rising student numbers and caused The Times to print another leader using a misof KINGSLEY AMIS for

a title. The first was quotation the publication of a letter, sent to universities by the Committee of Vice-Chancellors, describing discussions with the then Minister of State at the Department of Education, Mrs. SHIRLEY WILLIAMS, at the end of September, when she gave them new projections of the likely numbers who by 1980 would be clamouring to get into the universities. The second was the appearance of a book 23 in which three members of the L.S.E. Higher Education Research Unit question the adequacy of the Department of Education’s statistical forecasting, and suggest that the raising of the school-leaving age may increase later demand for higher education in a way which has not yet been foreseen. The first of these two news items gave rise to exactly the kind of sensational reporting which Ministers must fear when they are courageous enough to think aloud. Mrs. WILLIAMS explained to the Vice-Chancellors the evidence of the growth of sixth forms and for the expectation that by 1980 the number of potential university candidates will be 40% above the figure projected by the Robbins Committee in 1963. What has happened is that the trend upwards has followed and exceeded the higher of two lines on the graph which the statisticians described to the Robbins Committee. Robbins, from a combination of caution and reluctance to scare the politicians, had adopted the lower line. On the Robbins’ of the number hypothesis places required in higher education by 1980 worked out at 558,000, of which 346,000 were in universities. Now the total estimated 22.

R. F., Custer, J., Madden, J., Dajant, A. S., Rogers, W., Wangensteen, O. H. Am. J. Surg. 1969, 118, 21. 23. Decision Models for Educational Planning. By PETER ARMITAGE, B.SC., CYRIL SMITH, B.SC., PH.D., and PAUL ALPER, B.S.E.E. London: Allen Lane, the Penguin Press. 1969. Pp. 124. 75s.

Edlich,

number of places required, if the proportion of those obtaining two A levels who can be admitted is to remain at the Robbins (1963) level, goes up by 1980 to 727,000 and the university population could rise to around 450,000. Having laid out the facts, Mrs. WILLIAMS listed 13 possible changes to reduce the unit costs of university education or to restrict the level of demand and therefore limit total costs. One way of restricting expenditure would be to make entry much more selective by stiffening the entrance examination; this would have serious political, social, and educational repercussions. At the other extreme, the money could simply be pegged and the universities expected to cope with larger numbers by lowering their teaching standards. Between the two extremes there were the ideas which Mrs. WILLIAMS mooted-not Government policy or even the basis of policy, but the kind of thing which no sensible administrator could refrain from considering. These included obvious but controversial ideas such as loans instead of grants; cutting down on the percentages of foreign students; making student grants

dependent on promises to enter certain occupations as teaching; giving bright students the chance to complete their degrees in two years (or requiring them to do so). It also provided an opportunity to trot out the King Charles’ head of the university year and ways in which the expensive equipment and buildings could be more intensively used. All or any of these proposals could lower the quality of university life in some way (the same would be true of cutting down on gardeners and putting lawns down to concrete). There is a real sense, therefore, in

such

which more will mean worse; but it is in the sense of the quality of the university environment, not the quality of the student or his capacity to benefit. At all events, Mrs. WILLIAMS has learned that to take the universities into frank consultation and broach unpalatable ideas is to court misunderstanding. This is a pity because Ministers ought to be willing to promote intelligent public discussion and enable decision-making to take place against a more informed background of public opinion. This they will be less likely to do if speculative possibilities are headlined as imminent disasters. The book, by PETER ARMITAGE and his colleagues,23 is relevant to the university discussion because the figures for potential university entrants will be still higher if, as the writers suggest, raising the leaving age to 16 results in more people staying on to 17 and 18. They are, in fact, less than categorical. They are more concerned to show that a mathematical model can be constructed which would allow more adequately for the possible side-effect of raising the age, than to prove that a higher school-leaving age will actually increase the numbers of students with two A levels by 1980. Quite obviously it could increase the number of 17-year-olds in school without